Epidemiology of Brucellosis in Saudi Arabia

Assessment of knowledge, attitude, and practice related to brucellosis among livestock farmers and meat handlers in Saudi Arabia

Background

Brucellosis is a bacterial zoonotic infection that is endemic in Saudi Arabia and associated with clinical and economic impacts. Several studies from countries endemic for brucellosis evaluated the knowledge and attitude of livestock farmers regarding brucellosis. However, no such study was conducted in Saudi Arabia. This study aimed to evaluate the knowledge, attitude, and practice of livestock farmers and meat handlers in Saudi Arabia.

Methods

This was a cross-sectional questionnaire-based study, where participants were interviewed in-person in Arabic in livestock markets between September-December 2023. Convenient sampling was utilized. The questionnaire included basic demographics and questions to assess the knowledge, attitude, and practice toward personal protection and protection of the animals from brucellosis. The questionnaire was adapted from a previously validated survey and included 59 questions. Providing at least one correct answer to a certain question indicated a good knowledge about this item or a safe practice. The participants were divided into: farmers (shepherds working for the animal owners), commercial animal owners (those who rent a stockyard in the livestock market and employ farmers to sell their animals), and private animal owners (owners of private farms from which they sell their animals).

Results

545 participants were interviewed (n = 291 farmers, n = 118 commercial animal owners, n = 113 private animal owners, and n = 23 animal slaughterhouse workers). >90% have heard of brucellosis. Lack of education and short experience (<5 years) of working with livestock were negatively associated with good knowledge of brucellosis symptoms and transmission (OR, 0.30; 95%CI, 0.10-0.94; p = 0.038 and OR, 0.23; 95%CI, 0.08-0.62; p = 0.004, respectively). Taking sick animals to the veterinarian was reported by 61.2%, whereas 36.4% follow safe practices when disposing of aborted fetuses. While 34% consume raw milk, only 10% consume rare/medium-rare meat. 51.2% acknowledged the need for more information on brucellosis.

Conclusion

This study revealed the need to augment the knowledge of people working with animals, particularly those with no school education and those with short work experience, via providing educational visits or materials or through veterinarians. This should help them identify human and animal brucellosis symptoms and increase the knowledge on how to protect oneself and animals from this disease.

Brucellosis and Sacroiliitis Present as Acute Severe Hip Pain

Brucellosis is a zoonotic disease that is endemic in Saudi Arabia. It is transmitted to humans through direct contact with infected animals or by consuming unpasteurized dairy products. A 36-year-old Saudi man presented with left hip pain, fever, and a history of consuming unpasteurized milk. Sacroiliitis was documented by positive results from serological tests (ELISA) and magnetic resonance imaging. Treatment consisted of non-steroidal anti-inflammatory drugs (NSAIDs), doxycycline, rifampicin, and IV gentamicin.

Seroprevalence and molecular detection of brucellosis among Pakistani women with spontaneous abortion

Background

Human brucellosis is a neglected disease transmitted to humans from animals such as cattle, goats, dogs, and swine. The causative agents are bacteria of the genus Brucella, intracellular pathogens usually confined to the reproductive organs of their animal hosts causing sterility and abortions. The objective of the study was to determine the seroprevalence of brucellosis among women with spontaneous abortions (SAW) and compare this seroprevalence with that of healthy pregnant women (HPW).

Methods

The case-control study was designed to determine the seroprevalence and molecular detection of brucellosis in women who suffered from spontaneous abortion and healthy pregnant women of the Haripur District of Pakistan. A total of 770 blood samples (n = 385 for each group) were collected from 9 public and 11 private hospitals in Haripur District from December 2021-March 2023. Data on demographic features, epidemiological variables, and risk factors were collected from each participant by structured questionnaires. Initial screening for brucellosis was performed by Rose Bengal Plate Test followed by qRT-PCR for molecular detection of the genus-specific BCSP-31 gene of Brucella.

Results

The study showed that anti-Brucella antibodies were more found in SAW 23.63% (91/385) than in HPW 1.29% (5/385). Brucella specific DNA was amplified in 89.01% (81/91) seropositive samples of SAW. Demographic features and risk factors such as age, urbanicity, socioeconomic status, education, occupation, and animal contact were found significantly associated with brucellosis (p ≤ 0.05). Consumption of unpasteurized raw milk (OR = 18.28, 95%CI: 8.16-40.94) was found highly concomitant with seroprevalence.

Conclusion

This study reports the first evidence of involvement of brucellosis in spontaneous abortions in women of Pakistan. The study can be used to develop strategies for risk management during pregnancy, to raise awareness for brucellosis, and develop control programs.

Epidemiology of Reportable Bacterial Infectious Diseases in Saudi Arabia

INTRODUCTION

Bacterial infections have a significant impact on human health; they can cause severe morbidity and mortality, particularly in susceptible populations. Epidemiological surveillance is a critical tool for monitoring the population's health and facilitate the prevention and control of infectious disease outbreaks. Knowing the burden of bacterial communicable diseases is an initial core step toward public health goals.

METHODS

Saudi epidemiology surveillance data were utilized to depict the changing epidemiology of bacterial infectious diseases in Saudi Arabia from 2018 to 2021. The cumulative numbers of cases, demographics, and incidence rates were analyzed and visualized. Parametric tests were used to compare the difference in the mean values between categorical variables. Regression analysis was employed to estimate trends in disease rates over time. Statistical significance was set at p value ≤ 0.05.

RESULTS

The results revealed that brucellosis, tuberculosis, and salmonellosis were the most frequently reported bacterial infectious diseases in Saudi Arabia. Males were more significantly affected by brucellosis and tuberculosis infections than females. Salmonellosis infections were more significant among Saudi citizens, while pulmonary tuberculosis was more significant in non-Saudis. Interestingly, there was a decline in the incidence rates of numerous bacterial infectious diseases during the Coronavirus Disease 2019 (COVID-19) pandemic and COVID-19 restrictions. Some bacterial infectious diseases were rarely reported in Saudi Arabia, including syphilis and diphtheria.

CONCLUSIONS

The future perspective of this research is to enhance disease surveillance reporting by including different variables, such as the source of infection, travel history, hospitalization, and mortality rates. The aim is to improve the sensitivity and specificity of surveillance data and focus on the mortality associated with bacterial pathogens to identify the most significant threats and set a public health priority.

The Reasons Behind Long-Term Endemicity of Brucellosis in Low and Middle-Income Countries: Challenges and Future Perspectives

Brucellosis is a neglected worldwide zoonotic disease with more than 500,000 new human cases each year. Direct contact with infected animals and consumption of undercooked animal origin foods are the main routes of brucellosis transmission to humans. Although long endeavor has been applied to control and eliminate brucellosis from animal and human populations in developing countries especially in low- and middle-income countries (LMICs), the disease is still endemic in these regions. Many common or unique factors including raw milk consumption, unhygienic slaughter of livestock, extensive husbandry, budgetary limitations, misdiagnosis, and other conditions play a role in long-term endemicity of brucellosis in these locations. It has been shown that One Health is the only practical approach to control brucellosis; however, applying such methods is challenging in low-resource areas. In such conditions, brucellosis is continuously maintained in animals and repeatedly spread to human populations. In this article, factors playing a critical role in brucellosis endemicity, and the real conditions challenging the application of One Health approach in control of brucellosis are highlighted.

Evaluation of Clinical Preventive Management Provided by Primary Healthcare Physicians Against Brucellosis in Saudi Arabia

BACKGROUND

 Brucellosis is among the most common zoonotic bacterial infections, leading to major public health consequences in endemic areas such as Saudi Arabia. Primary healthcare is crucial in controlling brucellosis, as it serves as the frontline for disease prevention, early detection, and appropriate management. However, enhancing the contribution of primary healthcare to the entire brucellosis notification process is necessary to minimize the underreporting and inadequate data collection, which hinders the implementation of effective control measures.

OBJECTIVE

The objective of the study is to assess primary care physicians' knowledge and practice of clinical preventive management in Saudi Arabia regarding brucellosis using an adapted assessment tool featuring a semi-structured questionnaire.

SUBJECTS AND METHODS

The current study's design is a cross-sectional study based on a questionnaire. Three hundred and seventy-three primary healthcare physicians in Saudi Arabia were chosen for self-administered online standardized questionnaires.

RESULTS

 One-third of the participants answered all the knowledge assessment questions correctly. Most participants had more than 10 years of professional experience and were 40 or older. In response to the practice assessment questions, 210 physicians stated that they had encountered at least one case of brucellosis, and two-thirds had no compliance with the notification process of their cases.

CONCLUSION

The limited knowledge and improper practice of primary care physicians regarding human brucellosis are possible underlying reasons for the underdiagnosis and underreporting of brucellosis patients at primary health care clinics in Saudi Arabia. Most research indicates that implementing specific educational programs to improve knowledge is necessary for primary healthcare workers. Furthermore, enhancing the community interaction between healthcare centers and the community facilitates effective control measures against brucellosis.

Case report: Microangiopathic hemolytic anemia and thrombocytopenia in a child with Brucella infection

Thrombotic thrombocytopenic purpura (TTP) is a diffused microvascular occlusive disorder characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and ischemic organ dysfunction. In addition, this condition has been linked to an absence or dysfunction of ADAMTS13. Although TTP can occur due to various factors, such as bacteria, viruses, autoimmune disorders, drugs, connective tissue conditions, and solid tumors, it is a rare hematological complication associated with brucellosis. We describe the first case of a 9-year-old boy with acquired TTP with undetectable ADAMTS-13 assay secondary to Brucella infection. After initiating antimicrobial therapy, symptoms and laboratory abnormalities improved dramatically, with no recurrence of TTP in subsequent follow-ups.

An Epidemiological Study of Brucellosis in Different Animal Species from the Al-Qassim Region, Saudi Arabia

Brucellosis is a zoonotic bacterial illness that affects humans and a variety of domestic animals, especially ruminants. It is mostly transmitted through the consumption of contaminated drinks, foods, undercooked meat, or unpasteurized milk or contact with infected animals. Therefore, the present study aimed to investigate the seroprevalence of brucellosis in camels, sheep, and goat herds in the Qassim region, Saudi Arabia, using commonly used diagnostic serological procedures such as the Rose Bengal test (RBT), complement fixation test (CFT), and enzyme-linked immunosorbent assay (ELISA). The seroprevalence of brucellosis in camels, sheep, and goats was determined in the selected areas using a cross-sectional study design and a total of 690 farm animals of both sexes of different ages from the three animal species (274 camels, 227 sheep, and 189 goats). According to RBT results, 65 sera were positive for brucellosis, including 15 (5.47%) for camels, 32 (14.09%) for sheep, and 18 (9.50%) for goats. CFT and c-ELISA were performed as confirmatory tests on positive samples resulting from RBT. With c-ELISA, 60 serum samples were confirmed positive, in 14 (5.10%), 30 (13.21%), and 16 (8.46%) camels, sheep, and goats, respectively. There were 59 serum samples confirmed as positive for CFT, including 14 (5.11%), 29 (12.77%), and 16 (8.46%) for camels, sheep, and goats, respectively. Overall, the highest seroprevalence of brucellosis was found in sheep while the least was found in camels from the three tests (RBT, c-ELISA, and CFT). The highest seroprevalence of brucellosis was found in sheep while the least seroprevalence was found in camels. There was also a higher seroprevalence of brucellosis among female animals than males as well as among old animals than young animals. The study, thus, demonstrates brucellosis seroprevalence among farm animals (camels, sheep, and goats) and the significance of intervention measures against brucellosis incidence in both humans and animals through the creation of public awareness and other relevant policy measures such as livestock vaccination, effective hygiene management, and adequate quarantine or serological analysis for newly introduced animals.

Knowledge, attitudes, and practices regarding brucellosis among general population: A cross-sectional study from Jazan Province, Saudi Arabia

Objective

Brucellosis is an endemic zoonotic infection in Saudi Arabia, including Jazan Province, and epidemiological reports about this disease are limited. In this study, we aimed to investigate knowledge, attitudes, and practices regarding brucellosis among the general population of Jazan Province, southwestern Saudi Arabia.

Materials and Methods

This is a cross-sectional study conducted using a pretested questionnaire that assessed the level of knowledge, attitudes, and practices toward Brucellosis. The calculated sample size was 384, and 1,055 participants were included representing various genders, ages, and levels of education. Data were collected between March and April 2022 and analyzed using descriptive, chi-square, and t-test analyses.

Results

Only 50% of the included participants have heard about Brucellosis. Among those who had heard about Brucellosis, 70% had a good knowledge about Brucellosis and that was significantly associated with male gender, being healthcare workers (HCWs), and having a higher level of education. Participants who directly involved in animal care represented 9%, and attitudes and practices regarding brucellosis were varied from average to unsatisfactory. This variation was significantly affected by the level of knowledge.

Conclusion

About 50% of the general population of Jazan Province had never heard about Brucellosis, in a region found prevalent for this disease. Good knowledge was recorded in 70% of those who were aware of Brucellosis, which was significantly associated with the male sex, job as being HCW, and having a higher level of education. These results necessitate public awareness campaign activities to improve knowledge and practices, especially among women, the younger generation, and individuals with limited educational backgrounds. This action could reduce the burden of the disease.

Neurobrucellosis Complicated by Sensorineural Hearing Loss: A Case Report

Brucellosis is a zoonotic disease. It is also one of the neglected infectious diseases and is less well-known compared to other diseases. It is acquired from infected animals (cattle, sheep, goats, camels, pigs, or other animals) through the consumption of unpasteurized dairy products or contact with tissues or fluids. Sensory neural hearing loss (SNHL) in neurobrucellosis had been described in the literature, mostly as an incidental finding that otolaryngologists should consider in any patient with fever and a history of travel to the Middle East, Central or South America, or other brucellosis-endemic countries. We present a neurobrucellosis case with profound bilateral SNHL that was treated with combination antibiotic therapy for long periods of time and highlight the clinical course of the patient.

Brucellosis causing bone marrow aplasia in an 11-year-old patient with complete recovery after treatment

Brucellosis is one of the most prevalent zoonotic infections in the Middle East. The disease may present with a range of symptoms from a simple febrile illness to severe invasive infections affecting different organ systems (meningitis, osteomyelitis). In this paper we present an eleven-year-old girl who was diagnosed with “idiopathic bone marrow aplasia” and planned for hematopoietic stem cell transplant (HSCT), when pre-transplant work-up showed high brucella titers. The patient was started on doxycycline, rifampin and gentamicin initially, with discontinuation of the latter 3 weeks into therapy. She recovered completely after 8 months of treatment.

P-ANCA Systemic Vasculitis Induced by Brucellosis in an Elderly Male Patient

One of the most prevalent causes of vasculitis is bacterial infection. An infection that causes anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is uncommon and not reported frequently. We report a case of a 74-year-old male who presented with fever for ten days and was found to have brucellosis. Then, he was diagnosed with Guillain-Barré syndrome (GBS) and started on immunoglobulin (IVIG) for one week without a response. His fever was still persistent despite appropriate antibiotic therapy. Rheumatology evaluation revealed a history of multiple joint pain and swelling, elevated inflammatory marker, and a high titer of P-ANCA. Steroid therapy was started initially on the background of antibiotics therapy. His fever and other symptoms showed marked improvement after one week. However, P-ANCA titer was still elevated. The decision was made to treat the patient as a case of brucellosis-induced P-ANCA vasculitis. Azathioprine was added, and steroid was maintained for one month and then it was tapered gradually. All symptoms improved from the third month of follow-up except weakness from peripheral neuropathy with normalization of P-ANCA titer. His condition remained stable after six months of follow-up. Clinicians should be aware of the possibility of infection-induced vasculitis, particularly when patients' symptoms persist despite the appropriate use of antibiotics.

Knowledge, Attitudes, and Practices Regarding Brucellosis among Parents in Aseer Region, Southwestern Saudi Arabia

This study aimed to investigate the knowledge, attitudes, and practices regarding brucellosis among parents in the Aseer region of southwestern Saudi Arabia in order to estimate the population sectors that are at high risk for accidental exposure to brucellosis. This was a cross-sectional survey conducted in 2018, including 311 participants representing various genders, ages, and levels of education. Bivariate analysis showed a significant association of good awareness of the disease with the male gender and higher education levels. Of the 311 participants, 90.0% had good knowledge, whereas 10.0% showed inadequate knowledge about brucellosis. Practices and attitudes regarding brucellosis were satisfactory as participants did not eat meat from their own animals (52.7%), did not practice slaughtering (71.4%), did not participate in the birth of animals (91.3%), were not exposed to abortion in animals (93.2%), and practiced burial of aborted animal fetuses (59.2%). The practice regarding brucellosis was unsatisfactory as 66.6% never wore gloves when dealing with animals. The study concluded that the majority of parents showed fair and positive knowledge, attitudes, and practices regarding brucellosis and found that gender and education were determinants of satisfactory awareness.

Changes in the epidemiological characteristics of human brucellosis in Shaanxi Province from 2008 to 2020

In the present study, surveys of case numbers, constituent ratios, conventional biotyping, and multilocus sequence typing (MLST) were applied to characterize the incidence rate and epidemiological characteristics of human brucellosis in Shaanxi Province, China. A total of 12,215 human brucellosis cases were reported during 2008-2020, for an annual average incidence rate of 2.48/100,000. The most significant change was that the county numbers of reported cases increased from 36 in 2008 to 84 in 2020, with a geographic expansion trend from northern Shaanxi to Guanzhong, and southern Shaanxi regions; the incidence rate declined in previous epidemic northern Shaanxi regions while increasing each year in Guanzhong and southern Shaanxi regions such as Hancheng and Xianyang. The increased incidence was closely related to the development of large-scale small ruminants (goats and sheep) farms in Guanzhong and some southern Shaanxi regions. Another significant feature was that student cases (n = 261) were ranked second among all occupations, accounting for 2.14% of the total number of cases, with the majority due to drinking unsterilized goat milk. Three Brucella species were detected (B. melitensis (bv. 1, 2, 3 and variant), B. abortus bv. 3/6, and B. suis bv. 1) and were mainly distributed in the northern Shaanxi and Guanzhong regions. Three known STs (ST8, ST2, and ST14) were identified based on MLST analysis. The characteristics that had not changed were that B. melitensis strains belonging to the ST8 population were the dominant species and were observed in all nine regions during the examined periods. Strengthened human and animal brucellosis surveillance and restriction of the transfer of infected sheep (goats) as well as students avoiding drinking raw milk are suggested as optimal control strategies.

The incidence and clinical manifestations of human brucellosis in a referral hospital in Southern Saudi Arabia between 2015 and 2019

We determined the incidence and clinical manifestations of human brucellosis from patients who attended a referral hospital in South of Saudi Arabia. A record-based retrospective study was conducted from January 2015 to December 2019 at King Abdulla Hospital, Bisha, Saudi Arabia. Information on patients' demographic characteristics, detailed records of signs and symptoms, and the laboratory findings were reviewed. Of 6,586 patients included, 15.8% (n = 1,041) were infected with brucellosis. The age of infected individuals ranged from five to 95 years, with an average of 35.1 ± 21.2 years. Most infected patients were male (72.3%). Young adults (26-44 years) were the most common age group with the disease (34.1%). The annual rate of infection significantly decreased (P < 0.0001) from 33.2% in 2015 to 12.5% in 2019. An escalating number of brucellosis cases was seen in the spring and peaked during the summer. Fever (35.3%), joint pain (25.5%), generalized body ache (10.7%), and neurological symptoms (10.0%) were the most frequent clinical manifestation associated with brucellosis. Joint pain was commonly found among children (44.4%). Neurological findings were more frequent among adult patients. The study concluded that brucellosis is endemic in Southern Saudi Arabia and needs local health authority to implement preventive and educational program measures. Infected patients may present with diverse, nonspecific clinical manifestations that require intuition from clinicians to detect the disease.

Brucella Shunt Infection Complicated by Peritonitis: Case Report and Review of the Literature

Brucellosis is an endemic zoonotic disease in the Mediterranean basin and Middle East. The disease remains a diagnostic challenge due to an increasing trend of ambiguous and non-specific manifestations. We report a rare case of a 9-year-old boy who had a left frontotemporal arachnoid cyst with cystoperitoneal shunt who presented with fever for 2 weeks with gastrointestinal symptoms. He had no neurological manifestations. Diagnosis of Brucella shunt infection complicated with a peritoneal collection was established by isolation of the organism from cerebrospinal fluid (CSF) culture. Successful treatment was accomplished by shunt replacement and intravenous antibiotics followed by step-down oral therapy for an 18-month duration based on serological and radiological responses with no sequelae. We also reviewed the reported cases of CSF shunt infection in the literature for further guidance. Brucella shunt infection may be difficult to diagnose due to the diversity of signs and symptoms and the low yield on culture. Brucellosis should be always kept in mind in the differential diagnosis of patients living in endemic area with fever and non-specific symptoms. Diagnosis depends on a high index of suspicion. In addition to drug therapy, device replacement is advised to prevent treatment failure.

Spinal Brucellosis: A Case Report and Review of the Literature

Introduction:

The most common location of infection of brucellosis is the musculoskeletal system. It is estimated that the spine is involved in 2–54% of brucellosis infections, with the lumbar spine most commonly affected. We report an uncommon case of brucellar spondylodiscitis, in addition to the pathology, common presentation, and management of spinal brucellosis through additional literature review.

Case Report:

A 65-year-old Hispanic male presented to an orthopedic spine surgeon with signs and symptoms concerning for metastatic disease to the spine. Investigation revealed that the patient had the rare diagnosis of brucellar spondylodiscitis. This only became apparent after detailed questioning of the patient’s history revealed his employment within a Mexican meat slaughterhouse and a regular consumer of unpasteurized Mexican cheeses.

Conclusion:

Although uncommon, brucellosis spondylodiscitis should remain as a differential diagnosis in any patient who presents with back pain and fever. Detailed history taking and thorough physical examination remain vital in the work-up of brucellar spondylodiscitis. Understanding the pathology, radiographic findings, and necessary work-up are essential to properly treat this infection.

Brucellosis in Saudi Children: Presentation, Complications, and Treatment Outcome

Background

Brucellosis, an endemic disease in Saudi Arabia, has an infection rate of 70 per 100,000 people, with a varying morbidity rate in different parts of the country. The aim of this study was to assess the epidemiological and clinical features, laboratory findings, treatment modalities, complications, and outcomes in children with brucellosis.

Materials and methods

The medical records of 153 patients attending King Abdullah Specialist Children’s Hospital in Riyadh, Saudi Arabia, from January 2015 to January 2019 were reviewed retrospectively. Demographic data, laboratory test results, serum agglutination test titer, and the results of the blood cultures were obtained. The diagnosis of brucellosis was based on compatible signs and symptoms with a positive serology titer of ≥1:160 or a blood culture positive for Brucella species.

Results

The majority of the sample (69.6%, n=107) were males, with a mean age of 7.75 ± 3.28 years. Ingestion of unpasteurized camel dairy products was the most frequent transmission risk factor. The most prevalent presenting symptoms were constitutional and musculoskeletal symptoms. Six patients (3.9%) had complicated brucellosis, with neurobrucellosis diagnosed in three cases. Hospitalization for brucellosis was required in 15% of the patients. The majority (99.35%, n=152) of the patients had a serum agglutination test (SAT) titer of ≥1:160. A blood culture was positive in 52 (34%) of the 111 patients tested. The most frequently prescribed regimen was rifampicin + co-trimoxazole in 81 (52.9%) patients. Relapse occurred in a small proportion (4.6%, n=7), and the majority (95.4%, n=146) had a complete remission.

Conclusions

The main route of transmission was the ingestion of unpasteurized dairy products. Brucellosis had a wide range of clinical presentation, involving multiple organ systems. Neurobrucellosis was the most frequent complication. The SAT was the most useful and reliable test for the diagnosis of brucellosis. Most patients were successfully treated with rifampicin and co-trimoxazole for six weeks.